One Year Later: Protecting the Gains, Correcting the Flaws of Health Care Reform

The Patient Protection and Affordable Care Act (ACA) became law in March 2010, bringing with it onerous abortion restrictions but also the promise—and in some instances already the reality—of substantial improvements in insurance coverage for various reproductive health services. Still, reproductive health advocates will face three main tasks as they seek to hold on to these gains: fending off repeated attacks from health care reform opponents, working with federal and state policymakers to implement key provisions of the law, and fixing the things that health reform got wrong.

Among the most important early provisions of health care reform that went into effect in September 2010 is one requiring all new private health plans to cover a range of preventive health services without any out-of-pocket costs to consumers. The initial list of protected services includes many related to reproductive health, including breast and cervical cancer screening, screening and counseling for HIV and other STIs, and HPV vaccination.

This list will expand later this year, when the Department of Health and Human Services issues a set of new guidelines for women’s preventive health care that may include contraceptive counseling, services and supplies. Supported by a strong body of evidence, contraceptive services have long been recognized by government bodies and private-sector experts as a vital and effective component of preventive care. Contraceptive use helps women avoid unintended pregnancy and space their births, which in turn helps improve maternal and child health. And insurance coverage without cost-sharing is an inexpensive—or even cost-saving—way of helping women overcome obstacles to effective contraceptive use.

Another notable new feature allows states to expand Medicaid coverage specifically for family planning services to women and men otherwise ineligible for the program. This provision builds on the experiences of the 22 states that have already expanded coverage via a burdensome “waiver” process—which the legislation now allows states to avoid. The potential gains for women, families and society are enormous.

Even more significant gains are yet to be realized. Starting in 2014, the health reform law will expand insurance coverage and patient protections to tens of millions of Americans through a historic expansion of Medicaid and the establishment of new health insurance “exchanges” that will help individuals and small businesses purchase private insurance with federal subsidies. All of this should make family planning, maternity and STI services more affordable and accessible. In fact, the law has already expanded coverage for young adults by requiring private plans to extend dependent coverage to adult children younger than age 26. This provision should improve coverage and access to sexual and reproductive health care among young adults, the group most at risk for unintended pregnancy and STIs.

Yet, implementation of the overhaul faces several major, intertwined challenges. These include a historic budget crisis affecting Medicaid—which would see an influx of new participants under health care reform—and other health programs. Another major challenge is the shift in political power following the November 2010 elections, which swept into office opponents of health care reform at both the federal and state level. They have already launched a number of attacks on the legislation generally and the gains for reproductive health services specifically.

While fending off these attacks, reproductive health advocates will need to work with federal and state policymakers to promote the optimal implementation of key provisions of health care reform. This includes setting up the major infrastructures of health care reform—including the structure and authority of the upcoming health insurance exchanges, the scope of the benefits package to be required under plans for individuals and small businesses, and the expansion of Medicaid—so that it works for both individuals and safety-net providers seeking to meet the expected surge in demand.

Finally, reproductive health advocates face an uphill struggle in convincing Congress to fix problems in health care reform. In particular, extending Medicaid coverage brings with it an unprecedented expansion in the reach of the decades-old Hyde amendment, which prevents federal Medicaid dollars from going toward abortion coverage (except in the most extreme circumstances). More than two-thirds of new Medicaid enrollees are projected to be residents of states that have not countered this ban by using state revenues. Further, while private insurance plans on the exchanges may include abortion coverage, the law includes so many administrative hurdles that—combined with attacks on abortion coverage by state policymakers—it may end up dissuading insurers from offering the coverage at all.

Other shortcomings severely limit coverage options for millions of immigrants. Despite the major expansion to Medicaid under health reform, Congress refused to eliminate the long-standing policy that bars federal support for undocumented immigrants and recent legal immigrants under that program. In fact, undocumented immigrants are even barred from using their own funds to purchase private insurance plans in the new insurance exchanges.

In short, while some tangible gains for reproductive health have already been made under health care reform—and many important ones are still in the offing—these positive developments should not be taken for granted.